Diagnostic Assessment — Umbilical Hernia
Example 1 of 1 · fictitious patient (Veteran CJ)
Diagnostic Assessment
Umbilical Hernia
BOP Code: 92 of 2025 (Umbilical Hernia, Peri-Umbilical Hernia and Para-Umbilical Hernia)
RH Code: 91 of 2025 (Umbilical Hernia, Peri-Umbilical Hernia and Para-Umbilical Hernia)
ADF History
Veteran CJ, date of birth 04 June 1979, Australian Army, Terminal Operator (Royal Australian Corps of Transport), enlisted 15 February 1999, medically discharged 30 November 2018. Operational service: East Timor, 20 October 1999 to 18 April 2000 (warlike); Middle East Area of Operations, 01 September 2009 to 30 September 2010 (warlike); Afghanistan, 10 February 2013 to 15 September 2013 (warlike).
Occupational History
Terminal operators load, unload, stack and secure cargo at ports, airheads and logistics hubs. The work involves repeated manual handling of ration packs, water, ammunition boxes, engine parts and stores of 20 to 40 kilograms, much of it lifted from ground level or passed up onto trucks and pallets, often for most of a shift. Mechanical handling equipment is frequently unavailable or unserviceable in deployed locations, so loads are moved by hand.
In the Middle East and Afghanistan terminal operators work long shifts in heat, dust and smoke from burn pits and vehicle exhaust, with irregular meals, limited exercise facilities and high-calorie field rations. Respiratory irritation from dust and smoke, gastrointestinal illness and musculoskeletal strain are common occupational hazards of the trade.
History
Veteran CJ, a terminal operator in the Australian Army, developed an umbilical hernia on 20 September 2010 at the end of a 13-month warlike deployment in the Middle East, during which he manually lifted heavy cargo for several hours a day, gained weight to a BMI above 30 and developed a chronic cough from dust and burn-pit smoke. The hernia enlarged and incarcerated during his 2013 deployment to Afghanistan, when surgical repair was not available, and was repaired with mesh on 11 November 2013.
Timeline
- 12 Mar 2009 — Periodic health examination before deployment. Weight 94 kg, height 1.78 m, BMI 29.7. Abdominal examination was normal, with no umbilical swelling or cough impulse. He reported intermittent lower back pain from manual handling, managed with paracetamol and codeine, and mild exercise-induced asthma controlled with salbutamol. "abdomen soft, no hernia"
- 14 Feb 2010 — Seen at the role 1 health facility in the Middle East with a productive cough of eight weeks' duration, worse at night and after shifts near the burn pit. He described coughing fits of several minutes, sometimes to the point of retching. Spirometry showed reversible airflow obstruction and his asthma was reclassified as moderate persistent. Inhaled budesonide-formoterol was commenced. He was lifting cargo by hand for three to five hours on most shifts because two forklifts were unserviceable. "chronic cough, burn pit exposure"
- 28 Jun 2010 — Reviewed for constipation and straining at stool, attributed to regular codeine for lumbar strain from cargo handling and to dehydration in summer heat. Weight 101 kg, BMI 31.9. A coughing pattern persisting for six months was recorded. Macrogol was prescribed and fluid intake advice given. "straining at stool, BMI 31.9"
- 22 Sep 2010 — Presented to the role 1 facility with a painless soft swelling at the umbilicus first noticed two days earlier after a coughing fit while lifting a pallet of water. Examination showed a 1.5 cm reducible umbilical hernia with a positive cough impulse. He was advised to avoid heavy lifting and referred for surgical review on return to Australia. "reducible umbilical hernia 1.5 cm"
- 19 Jan 2011 — Ultrasound in Australia confirmed a 14 mm fascial defect at the umbilicus with herniation of pre-peritoneal fat on straining. A general surgeon recommended elective repair and the veteran was placed on the surgical waiting list. The referral was not actioned when he was posted interstate in mid-2011 and he was never given a date for surgery. "14 mm defect, elective repair"
- 24 Jun 2013 — During warlike service in Afghanistan he presented with increasing size and aching of the hernia after weeks of manual cargo handling and a three-day episode of gastroenteritis with repeated vomiting. Examination showed a 3.5 cm hernia that was tender and only partly reducible. No elective surgical capacity was available in theatre and he was returned to duties with lifting restrictions that operational demands did not allow him to observe. "3.5 cm, partly reducible, tender"
- 02 Aug 2013 — Episode of incarceration in Afghanistan, with severe umbilical pain and vomiting after lifting ammunition boxes. The hernia was reduced under sedation at the role 2 facility. Weight 106 kg, BMI 33.5. He was placed on light duties for the remaining six weeks of the deployment. "incarcerated hernia, reduced under sedation"
- 11 Nov 2013 — Open mesh repair of the umbilical hernia by a general surgeon in Australia. The operation note recorded a 32 mm fascial defect containing omentum with chronic inflammatory change, consistent with incarceration. He returned to restricted duties and was medically discharged in 2018 for his lumbar spine and asthma. "mesh repair, 32 mm defect"
Symptoms
At onset the veteran noticed a soft swelling at the umbilicus that appeared when he coughed, lifted or strained and disappeared when he lay down, with a dragging discomfort at the end of a shift. After onset the swelling slowly enlarged and became more uncomfortable with heavy lifting and coughing fits.
In 2013 the swelling became larger, tender and only partly reducible, with episodes of severe pain and vomiting when it became stuck. Since the mesh repair he reports occasional periumbilical discomfort with lifting and avoids loads above 15 kilograms.
Imaging
- 19 Jan 2011 — Ultrasound abdominal wall: "14 mm fascial defect at the umbilicus with herniation of pre-peritoneal fat on Valsalva. No incisional component."
- 26 Jun 2013 — Ultrasound abdominal wall (role 2 facility): "Umbilical hernia with a 31 mm neck containing omentum, only partly reducible on compression. No bowel within the sac."
Onset Date
The most likely date of onset of this condition is 20 Sep 2010.
At that date the veteran was in the final fortnight of a 13-month warlike deployment in the Middle East, working as a terminal operator at a logistics hub. He had a chronic cough from asthma aggravated by dust and burn-pit smoke, was straining at stool from codeine-related constipation, had a BMI above 30 and was lifting cargo by hand for several hours on most shifts. He first noticed the umbilical swelling after a coughing fit while lifting a pallet of water.
This date is appropriate because his pre-deployment examination of 12 March 2009 recorded a normal abdomen with no hernia, and he first presented with a reducible umbilical hernia on 22 September 2010, two days after onset. It falls within continuous full-time warlike service.
For the heavy lifting factor, the 12 months before onset run from 20 Sep 2009 to 20 Sep 2010. Throughout that period he was deployed in the Middle East and lifted loads of 20 to 40 kilograms by hand for three to five hours on most shifts, on more days than not. For the chronic elevation of intra-abdominal pressure factor, his chronic cough had been present since December 2009 and his straining at stool since June 2010, and both were present on 20 Sep 2010. His BMI was 31.9 on 28 Jun 2010 and remained above 30 at onset.
For the worsening factors, the period after onset runs from 20 Sep 2010 to the documented worsening on 24 Jun 2013, confirmed by ultrasound on 26 Jun 2013, when the hernia neck had enlarged from 14 mm to 31 mm and the hernia had become partly irreducible, followed by incarceration on 02 Aug 2013. At the worsening he was on warlike service in Afghanistan, lifting cargo by hand, had recently vomited repeatedly with gastroenteritis, continued to cough and had a BMI of 33.5. Elective repair, recommended on 19 Jan 2011, had not been provided before the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Umbilical Hernia (ICD-10 K42.9), under the Statements of Principles concerning umbilical hernia, peri-umbilical hernia and para-umbilical hernia, Balance of Probabilities No. 92 of 2025 and Reasonable Hypothesis No. 91 of 2025.
An umbilical hernia is a protrusion of intra-abdominal tissue, usually pre-peritoneal fat or omentum and sometimes bowel, through a defect in the linea alba at or around the umbilicus. In adults it is an acquired condition, caused by weakening of the umbilical fascia under repeated or sustained rises in intra-abdominal pressure, such as obesity, chronic cough, straining and heavy lifting. Without repair the defect tends to enlarge, and the hernia can become irreducible, incarcerated or strangulated, which is a surgical emergency.
The diagnosis followed a year of heavy manual lifting, weight gain and chronic coughing on warlike service in the Middle East. It began on 20 September 2010, was confirmed on ultrasound in January 2011, worsened with incarceration in Afghanistan in 2013 and was repaired with mesh in November 2013.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
20 September 2010.
When did the veteran first present to a health / medical provider for this condition?
22 September 2010.
When was the condition confirmed / formally diagnosed?
22 September 2010.
When did the veteran first present to you (or your practice) for this condition?
18 June 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made clinically on 22 September 2010 by the finding of a 1.5 cm reducible swelling at the umbilicus with a positive cough impulse, and confirmed by ultrasound on 19 January 2011, which showed a 14 mm fascial defect at the umbilicus with herniation of pre-peritoneal fat on straining. The veteran had no previous abdominal surgery, so this is a primary umbilical hernia and not an incisional hernia. It meets the Statement of Principles definition of a protrusion of intra-abdominal tissue through a defect in the abdominal wall in the region of the umbilicus.
The clinical worsening is documented by repeat ultrasound on 26 June 2013, which showed the hernia neck had enlarged to 31 mm and the hernia was only partly reducible, and by the episode of incarceration on 02 August 2013 that required reduction under sedation. The operation note of 11 November 2013 recorded a 32 mm defect containing omentum with chronic inflammatory change, confirming the diagnosis and the worsening.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 20 September 2010, after 1 July 2004, during continuous full-time warlike service in the Middle East. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in the Middle East from 2009 to 2010, where the hernia began, and in Afghanistan in 2013, where it worsened and incarcerated.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Umbilical Hernia, Peri-Umbilical Hernia and Para-Umbilical Hernia, No. 92 of 2025
Causative factors
Factor 9(1): having a Body Mass Index (BMI) of 30 or greater at the time of clinical onset or clinical worsening; — MET
- The veteran's weight rose from 94 kg in March 2009 to 101 kg on 28 June 2010, a BMI of 31.9 at a height of 1.78 m, and it remained above 30 at the onset on 20 September 2010. By the worsening in June 2013 his weight was 106 kg, a BMI of 33.5. The weight gain followed a lumbar strain from cargo handling in peacetime service in 2008, which stopped him running, and the high-calorie ration diet and long shifts of service life. Central obesity raises resting intra-abdominal pressure and loads the umbilical fascia.
Factor 9(2): having chronic (intermittent or continuous) elevation of pressure within the abdominal cavity at the time of clinical onset; — MET
- At onset on 20 September 2010 the veteran had two documented sources of chronic intermittent elevation of intra-abdominal pressure. He had a chronic productive cough from December 2009, with coughing fits of several minutes recorded on 14 February 2010, from asthma first diagnosed in peacetime service in 2007 and made moderate persistent by dust and smoke. He also had chronic constipation with straining at stool from June 2010, caused by codeine prescribed for his service-related lumbar strain. Both were present at onset, and the hernia appeared after a coughing fit.
Factor 9(3): having acute or chronic (intermittent or continuous) elevation of pressure within the abdominal cavity at the time of clinical worsening; — MET
- At the worsening documented on 24 June 2013 the veteran had acute elevation of intra-abdominal pressure from three days of repeated vomiting with gastroenteritis and from heavy manual lifting of cargo, on a background of chronic cough from asthma and continued straining at stool. The incarceration of 02 August 2013 followed lifting ammunition boxes. The hernia neck had enlarged from 14 mm in January 2011 to 31 mm on 26 June 2013.
Worsening factors
Factor 9(4): inability to obtain appropriate clinical management for umbilical hernia, peri-umbilical hernia or para-umbilical hernia before clinical worsening. — MET
- A general surgeon recommended elective repair on 19 January 2011 and the veteran was placed on a Defence-arranged surgical waiting list, but the referral was not actioned after his posting interstate in mid-2011 and no operation date was given. The hernia remained unrepaired for almost three years and enlarged and incarcerated before it was finally repaired on 11 November 2013. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management before clinical worsening.
Reasonable Hypothesis — Statement of Principles concerning Umbilical Hernia, Peri-Umbilical Hernia and Para-Umbilical Hernia, No. 91 of 2025
Causative factors
Factor 9(1): having a Body Mass Index (BMI) of 30 or greater at the time of clinical onset or clinical worsening; — MET
- During his warlike deployment in the Middle East the veteran's BMI rose to 31.9 by 28 June 2010, with long shifts, high-calorie rations and no opportunity to exercise, and it was above 30 at onset on 20 September 2010. On warlike service in Afghanistan his BMI was 33.5 on 02 August 2013, at the time of the worsening and incarceration.
Factor 9(2): having chronic (intermittent or continuous) elevation of pressure within the abdominal cavity at the time of clinical onset; — MET
- On warlike service in the Middle East the veteran developed a chronic productive cough from December 2009, caused by asthma aggravated by dust and smoke from burn pits near the logistics hub, with coughing fits recorded on 14 February 2010. He also strained at stool from June 2010 because of codeine taken for lumbar strain from deployed cargo handling and dehydration in summer heat. Both were present at onset on 20 September 2010, and the hernia appeared after a coughing fit while lifting.
Factor 9(3): having elevation of pressure within the abdominal cavity due to lifting heavy loads for at least 1 hour per day, on more days than not, over a period of at least 12 months before clinical onset; — MET
- The 12 months before onset run from 20 September 2009 to 20 September 2010, all within his warlike deployment in the Middle East from 01 September 2009. Throughout that period he lifted ration pallets, water, ammunition boxes and stores of 20 to 40 kilograms by hand for three to five hours a shift on most days, because forklifts were unserviceable, as recorded on 14 February 2010. Each lift was performed with a held breath, raising intra-abdominal pressure.
Worsening factors
Factor 9(4): having acute or chronic (intermittent or continuous) elevation of pressure within the abdominal cavity at the time of clinical worsening; — MET
- On warlike service in Afghanistan the veteran had repeated vomiting from gastroenteritis in June 2013, continued to lift cargo and ammunition by hand because operational demands did not allow his lifting restrictions to be observed, and continued to cough from asthma aggravated by dust. These were present at the worsening documented on 24 June 2013 and at the incarceration on 02 August 2013, which occurred while lifting ammunition boxes.
Factor 9(5): inability to obtain appropriate clinical management for umbilical hernia, peri-umbilical hernia or para-umbilical hernia before clinical worsening. — MET
- Elective repair recommended in January 2011 was never scheduled, and during warlike service in Afghanistan in June 2013 no elective surgical capacity was available in theatre, so the enlarging, partly irreducible hernia could not be repaired. He was returned to duties and the hernia incarcerated on 02 August 2013. The delay to repair until 11 November 2013 was an inability to obtain appropriate clinical management before clinical worsening.
The % contribution of the causes is 100% and significant.
Sequelae
The umbilical hernia is in part a sequela of the veteran's accepted conditions: the obesity that followed his lumbar strain, the chronic cough from his service-related asthma, and the constipation caused by codeine prescribed for his lumbar spine. The incarceration in 2013 left chronic inflammatory change in the herniated omentum and required mesh repair, and he has persisting periumbilical discomfort on lifting.
Unintended Consequence
Met. The chronic straining at stool that contributed to the onset of the hernia was an unintended consequence of codeine prescribed by Defence medical officers for the veteran's lumbar strain while he was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. A general surgeon recommended elective repair on 19 January 2011, but the Defence-arranged referral lapsed when the veteran was posted interstate and he was never given a date for surgery. On warlike service in Afghanistan in 2013 no elective surgical capacity was available and his lifting restrictions could not be observed. The hernia enlarged from a 14 mm to a 31 mm defect and incarcerated before repair on 11 November 2013. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the lapsed referral and the operational unavailability of surgery amount to an inability to obtain appropriate clinical management. The delay of almost three years between the surgical recommendation and repair is itself indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 12 Mar 2009, Periodic health examination, Medical Officer, Garrison health centre
- 14 Feb 2010, Outpatient health record and spirometry, Medical Officer, Role 1 health facility, Middle East
- 28 Jun 2010, Outpatient health record, Medical Officer, Role 1 health facility, Middle East
- 22 Sep 2010, Outpatient health record, Medical Officer, Role 1 health facility, Middle East
- 19 Jan 2011, Ultrasound abdominal wall, Radiologist
- 19 Jan 2011, Surgical consultation, General surgeon
- 24 Jun 2013, Outpatient health record, Medical Officer, Role 1 health facility, Afghanistan
- 26 Jun 2013, Ultrasound abdominal wall, Role 2 facility, Afghanistan
- 02 Aug 2013, Emergency treatment record, Role 2 facility, Afghanistan
- 11 Nov 2013, Operation report, General surgeon
- Statement of Principles concerning Umbilical Hernia, Peri-Umbilical Hernia and Para-Umbilical Hernia (Balance of Probabilities) No. 92 of 2025, Repatriation Medical Authority
- Statement of Principles concerning Umbilical Hernia, Peri-Umbilical Hernia and Para-Umbilical Hernia (Reasonable Hypothesis) No. 91 of 2025, Repatriation Medical Authority
